APPLICATION FOR MEMBERSHIP

NAME (Last, First, MI): ____________________________________ Male Female

Marital Status: Single Married Maiden Name (if applicable) ___________

HOME ADDRESS _________________________

_________________________ ZIP _________ Home Phone ____________________


BUSINESS ADDRESS:____________________________

___________________________ ZIP ________ Business Phone: ___________________

Please send mail to: Home Business

Date of Birth: ___/____/____

Optometry School Attended: ____________ Graduation Date: ____/____/_____

Original License Date: ___/___/____ State(s) where licensed: _____________________________

Date Entered Active Duty: ___/___/____

IF NOW ON ACTIVE DUTY, PLEASE CIRCLE BRANCH:

USA USN USAF PHS VA Civil Service

IF ASSOCIATE, PLEASE CIRCLE PREVIOUS SERVICE:

USA USN USAF PHS VA Civil Service

IF ASSOCIATE, CURRENTLY: RESERVE NATIONAL GUARD PART TIME VA PART TIME CIVIL SERVICE

PARTIAL PRACTICE MEMBERSHIP: PARTIAL PRACTICE

STATEMENT: I certify that I practice fewer than 20 hours per week in a federal facility and do not have any other optometric work for which I am compensated. I also promise to notify the AFOS Executive Director if my status changes. _____ (please initial)

STUDENT: Service providing scholarship: ____________

If you are eligible to join the AOA through AFOS, were you a previous AOA Member? Yes No
If yes, affiliated organization(s) and date(s): ___________________________________________________


REMEMBER: DO NOT SEND DUES PAYMENTS TO THE AOA. Make checks payable to AFOS and send all payments to:

EXECUTIVE OFFICE
411 SWEETGRASS COURT
GREAT FALLS, MT 59405-1325

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